The ‘Taming’ of Health Care
Acquired Infections (HCAI)
Dr. Rashmi Sharma
Consultant Microbiologist/Deputy DIPC
FRCPath, MD, MRCOG
14/10/2011
The ‘taming’ of HCAI
• Define HCAI - cost to the patient and NHS
• Trust priority
• Antimicrobial Resistance
• MRSA and Clostridium difficile (C.diff) rates
compared to previous years
• What is new?
World Health Organisation (WHO)
definition - HCAI
•
Patient admitted for reason other than infection
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Not present or incubating at admission
>48h
Post discharge
Occupational infections in staff
HCAI
• 9% of all inpatients have HCAI at any one
time
• 300,000 HCAI/year
• 5000 deaths and contribute to 15,000/year
deaths
• £1 billion/year National Audit Office:
- length of stay (LoS) - 2.5 times longer
- hospital costs 3 times higher
- higher GP, district nurse and hospital
costs after discharge than uninfected
patients
HCAI: Collateral damage
DIRECT:
• £millions: Cost per infection episode; LoS;
• Lost work days
• Mortality; morbidity; complications
• PENALTY for breaching trajectory
INDIRECT:
• Reputation, media & patient choice
• Litigation
• Staff morale & team confidence
• KPI
Proactive Approach
•The Infection Prevention Committee is ‘led’ by the
CEO
•Trust is committed to reducing HCAI, key priority
•Case of C.diff or MRSA bacteraemia mandates
involvement of an ED
• Introduction of ‘antimicrobial stewardship’
Proactive Approach
•Re-invigorating and massive launch of ‘hand
hygiene’
• Audits and surveillance
• Achieving and ‘bettering’ trust targets
•Launched pilot project- HPAT
•Working closely with our partners in the
community
Global Crisis
Antibiotic resistance –
A patient safety issue for all hospitals
• The emergence, selection and spread of
resistant bacteria in hospitals is a major
patient safety issue.
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9
Infections with antibiotic-resistant bacteria can result in increased patient
morbidity and mortality, as well as increased hospital length of stay.1-2
Antibiotic resistance frequently leads to a delay in appropriate antibiotic
therapy.3
Resistance combined with poor infection control practice exacerbates the
problem
Resistant organisms in faeces contaminate environment outside hospital
contributing to increased community incidence of MSR organisms
Inappropriate or delayed antibiotic therapy in patients with severe
infections is associated with worse patient outcomes and sometimes
death.4-6
The Inverse Relationship
Antibacterial resistance
. Antibacterial R&D
1998
YEARS
2004
Antimicrobial Stewardship
• Launched recently
• Revision of the existing antimicrobial guidance in
the Trust and the community
•Policies and revised prescription charts
introduced to curb prolonged use of antibiotics
•Laboratory antimicrobial stewardship
•Ensure prudent prescribing
Blackpool Teaching Hospitals NHS Foundation Trust
Actual Performance MRSA Bacteraemias
30
Cummulative Number of Cases
27
24
21
18
15
12
9
6
3
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Month
1st April 2007 - 31st March 2008
1st April 2010 - 31st March 2011
1st April 2008 - 31st March 2009
1st April 2011 - 31st March 2012
1st April 2009 - 31st March 2010
Mar
Comparison of Blackpool Teaching Hospitals NHS Foundation Trust
with the National Rate for MRSA Bacteraemias per 100,000 bed days
5
4.5
4.3
MRSA Bacteraemia Rate
4
3.5
2.7
3
2.5
1.8
2
1.5
1
1.4
1.3
1.0
0.5
0
April 2008- March 2009
April 2009- March 2010
Year
National Rate
Blackpool Teaching Hospitals
April 2010- March 2011
Blackpool Teaching Hospitals NHS Foundation Trust
Actual Performance for Clostridium Difficile Infections
Cummulative Number of Cases
350
300
250
200
150
100
50
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Month
1st April 2007 - 31st March 2008
1st April 2010 - 31st March 2011
1st April 2008 - 31st March 2009
1st April 2011 - 31st March 2012
1st April 2009 - 31st March 2010
69% reduction achieved on rates of C.diff
infection when comparing 2010 to 2007
Mar
National Audit Office
• MRSA:
between 2003-04 and 2008-09 we estimate that the
NHS has saved between £45-59 million in treatment
costs by reducing the rates of MRSA bloodstream
infections
and
• C-diff:
between £97-204 million from 2006 to end of 2008
by reducing the rate of C.diff infections
[www.nao.org.uk ]
Initiatives in BTH for tackling
C.diff
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Antibiotic Stewardship Programme
including revised formulary, 5-day stop,
enhanced Micro support
Hand hygiene, prompt
identification/isolation, barrier nursing,
various audits
C.diff MDT meetings – disseminate
learning issues to entire nursing / medical
team
Audit & Surveillance
AUDIT:
• An evaluation of system or processes.
• We perform audit to measure aspects of care
provision against set and agreed standards.
SURVEILLANCE:
• Comes from the French for “watching over”.
• The monitoring of a behaviour, activities or other
changing information.
• In Infection Prevention it is used to monitor trends
and patterns in disease/illness/infection.
What Next?
• Emerging global threat- carbapenemase
producers (extremely resistant bacteria)
• Screening for these is required- National
recommendation
• www.hpa.org.uk- more information on
carbapenemase can be found on this
website
Extremely resistant bacteria
• MDR is defined as non-susceptibility to at least
one agent in three or more antimicrobial
categories
• XDR is defined as non-susceptibility to at least
one agent in all but two or fewer antimicrobial
categories (i.e. bacterial isolates remain
susceptible to only one or two categories)
• PDR is defined as non-susceptibility to all
agents in all antimicrobial categories (i.e. no
agents tested as susceptible for that
organism)
Measures to combat it
• Screening high risk patients
• Environmental hygiene
• Hand hygiene
• Antimicrobial stewardship
Home Parental Antibiotic Therapy
(HPAT) - Advantages
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Quality of treatment experience
Reduced risk of HCAI
Reduced hospital stay
Release of hospital beds
Cost-effective care
Return to work possible
Patient eligibility
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Medically stable
Meets inclusion/exclusion criteria
Appropriate IV access
Home circumstances appropriate
– Support
– Communications
– Facilities
Blackpool Teaching Hospitals
• HPAT: June 2011
• June:
• Sternal wound infection
• Liver abscess
• July 2011:
• Cellulitis [referred from Lancaster HPAT team]
• Cellulitis [GP referral]
• Great team work
• Enhancing quality project across
whole health economy
The Role of Hand Hygiene in
The ‘Taming’ of HCAI’s
Sharon Mawdsley Lead IPN
Launch of new Hand Hygiene
Policy 2011
Infection Prevention Team
Why change the policy?
• A doctors covert audit in 2010 showed a 37%
compliance rate in hand hygiene
• In 2011, another covert audit showed 35% compliance
• Traditional audits show a compliance average of 95%
• Is this the Hawthorne effect?
• Clostridium difficile rates not improving as well as
they should be
• We had two cases in April 2011
• 10 cases in May 2011
• It is highly likely that non-compliance was a
contributing factor
• There needs to be clear consequences for noncompliance
So what are we doing about it?
• Educating all staff and visitors
• Promoting the WHO five moments of hand hygiene
• Promoting competition through displaying audit
results on the intranet
• Taking this information to staff in their own areas
• Re-issuing the ‘pledge’
• Implementing a new covert audit process
• Outlining what the consequences of non-compliance
are
• Equipping staff with all the tools they need to be
compliant
So what can staff do about it?
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Read and sign the pledge
Memorise the five moments and implement them
Challenge their colleagues
Be courteous if they are challenged
Adhere to uniform policy/dress code
Be bare below the elbows when in the patient zone
Use appropriate PPE
Use appropriate hand decontamination methods for
each activity
So what are the consequences for
staff?
• Peers, managers and covert auditors will informally
challenge non-compliance
• Covert auditors will also take names. These names
will be given to their manager
• Initial episode of non-compliance observed by an
auditor will be dealt with by a manager verbally
• Repeated episodes will result in counselling by a
manager
• Further episodes will lead to formal disciplinary
action up to and including dismissal
So what are the 5 moments for
staff?
What is the patient zone?
Patient zone
• This is an area in the immediate vicinity of
the patient where care is provided
• It is an area which is likely to be heavily
colonised with the flora of a patient
• It can be difficult to describe in certain care
settings and may be mobile in others
• In this Trust, the patient zone is taken to be
inside the curtains
• In a community or out patient setting, the
zone is wherever the patient is examined or
cared for
Moment 1
Before patient contact
• WHEN?
• Clean your hands when approaching a
patient at the point of care
• WHY?
• To protect the patient from potential
pathogens carried on your hands
Moment 2
Before a clean/aseptic procedure
• WHEN?
• Clean your hands immediately before any
clean/aseptic procedure
• WHY?
• To protect the patient from potential
pathogens from the environment and
themselves being introduced invasively
Moment 3
After body fluid exposure risk
• WHEN?
• Clean your hands immediately after an
exposure risk to body fluids, including after
glove removal
• WHY?
• To protect yourself and the healthcare
environment against potential pathogens
from the patient and patient zone
Moment 4
After Patient Contact
• WHEN?
• Clean your hands after touching a patient, when
leaving the point of care (patient zone)
• WHY?
• To protect yourself and the healthcare environment
against potential pathogens from the patient
• The aim here is to prevent potential pathogens from
the patient crossing the boundary between the patient
zone and the healthcare zone
Moment 5
After contact with patient surroundings
• WHEN?
• Clean your hands after touching any object
or furniture in the patient zone, even if the
patient is not present or has not been
touched, when leaving the patient zone
• WHY?
• To protect yourself and the healthcare
environment against potential pathogens
from the patient zone
What are the five moments for
visitors and how will they know
what they are?
Moment 1
ON ENTERING A WARD
• When? Use the alcohol hand rub located at the
entrance.
• Why? To prevent taking harmful bacteria or
viruses into the ward environment.
Moment 2
BEFORE PATIENT CONTACT
• When? Clean your hands when approaching the
patient at their bedside.
• Why? To protect the patients skin from harmful
bacteria or viruses.
Moment 3
BEFORE ASSISTING WITH PATIENT MEALS
• When? Before you handle patients food.
• Why? To protect the patient from swallowing
harmful bacteria or viruses.
Moment 4
AFTER VISITING THE TOILET OR BATHROOM
• When? Please wash and dry your hands before
leaving the toilet or bathroom.
• Why? To prevent you from spreading harmful
bacteria or viruses around the hospital
environment.
Moment 5
AFTER CONTACT WITH THE PATIENT
SURROUNDINGS
• When? Clean your hands when you leave the
patients bed side.
• Why? To protect yourself and to prevent
spreading harmful bacteria or viruses around
the hospital environment.
How will they know?
• They will be politely reminded by staff
• Coming soon to a wall near you…......
Any Questions?